September 15, 2008

Still a Ways to Go: Widespread EHR Adoption Remains Off in the Distance
By Lindsey Getz
For The Record
Vol. 20 No. 19 P. 12

Experts analyze the reasons why facilities are slow to switch to electronic health records and offer ideas on how to reverse the tide.

To many, it’s no big surprise that electronic health record (EHR) systems have had a slow adoption rate. Besides the cost and learning curve involved, physicians have seen several EHR companies go under, and that’s made them even more apprehensive about investing in the technology.

But a recent New England Journal of Medicine study sheds some light on just how slow those rates have been. According to the study, only 4% of U.S. physicians use comprehensive EHR systems, including safety features such as drug interaction prompts. Another 13% say they use a more basic EHR system without the added safety features.

In light of these numbers, we’ve asked industry experts to weigh in on some of the problems and potential solutions.

Money, Money, Money
In The New England Journal of Medicine study, cost was the main reason cited for stagnating EHR adoption rates, but insiders say there’s a lot more to it than that. “I don’t think it’s the cost that has doctors concerned,” says Thomas Thornton, PhD, a senior research scientist at Perceptive Sciences. “Doctors will pay a lot of money for expensive equipment that will increase their productivity and make them more efficient. It’s whether they think EHRs will be worth the cost. The bottom line is that cost wouldn’t be such a major issue if they believed the system brought value to the firm. Nobody would care about that initial expense if it increased productivity and ultimately brought in more money.”

For physicians concerned about up-front costs, measures have already been taken to help alleviate some of the pressure. “There are significant tax credits and financial incentives already out there,” says Michael Nissenbaum, president and CEO of iMedica Corporation, an EHR software vendor. “But physicians also need to understand that this is an investment, so they will not only make their initial costs back, but in the next five years, they could make an extra $125,000.”

And new incentives are still being created. “We are talking with some physician insurance carriers to see if there could be an offset of the practice’s malpractice premium if they’ve integrated an EHR system,” says Karen M. Bell, MD, director of the Office of Health Information Technology Adoption at the Office of the National Coordinator for Health Information Technology.

Even without incentives, there are plenty of affordable systems. “Instead of charging a large up-front cost plus all the software maintenance on top of that, we take the approach of having a lower cost solution based on a monthly subscription,” says Jeff Gunther, president of Meddius, an integration technology company. “The cost is easier for the practice to absorb because of it being sold on a subscription basis.”

But the bottom line for most physician practices is whether they’ll be able to turn that initial investment into steady revenue. “You’ll hear the term return on investment a lot, but there is no magic wand or no silver bullet,” says Mary P. Griskewicz, MS, FHIMSS, senior director of ambulatory health information systems at HIMSS. “Every practice has different needs and will have different returns on their investment. Some practices may have a high transcription cost, and an EHR system may help them reduce that cost. Other practices may not have had transcription costs to begin with. We want to help practices to understand the meaning of return on investment, so we have set up a baseline calculator on our Web site as a helpful tool. The point is to help physicians start thinking about what their return on investment could be.”

The Perceived Risk of Integration
Taking the Pulse, a survey completed by market research and advisory firm Manhattan Research, found that the intensity of implementation, which usually takes between eight months to one year, was one of the main reasons physicians were suspicious of adopting EHRs. Integration encompasses cost concerns, as well as the up-front time and energy required to set up an EHR system.

In other words, physicians are concerned about the risk involved in implementing a new system. “Physicians are risk adverse,” says Jacob Reider, MD, medical director of clinical solutions at Misys Healthcare. “Our job is to find methods of reducing risk for our patients. We want to help you lower your risk of dying from a heart attack or having a stroke. Considering the fact that avoiding risk is what we do for a living, it’s obvious that we would have some concerns about something that appears to be risky.”
“Physicians, by their nature, are very cautious,” agrees Nissenbaum. “They are going to need to weigh the opportunity against the risk involved.”

So what’s the best way for physicians to overcome those feelings of uncertainty? “I acknowledge the risks involved when I talk to other physicians about EHRs,” says Reider. “But we achieve nothing if we don’t assume any risk in life. Physicians need to take a close look at their practice and then weigh the risks vs. benefits of EHR implementation. Ultimately, the benefits will outweigh the risks.”

Nissenbaum says his company has addressed physicians’ uncertainties with a trial program. “Our company removes the risk that physicians are feeling with a program called ‘Take a Tablet,’” says Nissenbaum. “It puts the application into the physicians’ hands on a tablet, and they are free to create and modify it in any way they like. It’s a seven- to 10-day test drive, and it lowers the physicians’ concern over what the sales guy is saying the program does and what it really does.”

In addition, there are also plenty of resources out there that can ease the education and implementation process. “That’s what HIMSS is about,” says Griskewicz. “Adoption rates have been low because it’s not just about cost but also about education. HIMSS can help with that learning curve. We can provide clinicians with plenty of electronic resources, such as electronic newsletters, that the practice can receive for free. All they have to do is sign up. And we have all kinds of tools and policy updates that can be found right on our Web site.”

Computer Skills Required
Physicians also say their lack of IT knowledge is a major reason for their uncertainty about adopting EHRs. “Physicians don’t go to school to understand information technology,” notes Griskewicz. “It may be the way the industry is going, but it’s not something that physicians are familiar with.”

The problem with many EHR systems is that they were designed by software engineers who may not be familiar with how doctors work, adds Thornton. “As a piece of software, they make a lot of sense, but for a physician who may not be familiar with operating software in the first place, they don’t,” he explains. “The interface of these systems often uses a tree structure or check boxes, so something as simple as a doctor looking at his own chart or progress notes and wanting to circle a plus or a minus may require drilling down through many screens and going through many check boxes. I’ve had doctors demonstrate how doing the simplest task can require so much time in navigating around that it was interfering with their practice. They felt they couldn’t interact with the patient.”

Many practices have considered the idea of hiring on-site technical support to alleviate these problems and aid in training, but this isn’t always cost-effective and can add even more time to the integration process. “Most physicians’ offices don’t have a lot, or any, IT staff, so we believe in a client-based approach to deal with this issue,” says Gunther. “Physicians want something that they can plug in and it works easily from there. We provide that and our device is remotely managed, so there’s no need to be hiring an entire IT staff.”

“Our company is an example of one that has a system which is easily understood and very tangible, even to a doctor who lacks that computer background,” adds Reider. “We have a fairly new product called Misys MyWay that you sign up for, plug in, and you’re off. We mitigate the risk by saying, ‘You don’t need to buy a server, and you don’t need to hire an IT person. We’re your partner for all that.’ It’s an attractive way for companies to adopt an EHR without taking out a lease on equipment or having to take a large financial risk on something that seems scary and hard to understand.”

Security Concerns
Going hand-in-hand with a lack of IT understanding are worries about security. Those who are wary about switching to a computerized world may also be concerned about the safety of electronically stored records. “A lot of physicians have concerns in the areas of privacy and security,” acknowledges Bell. “They ask, ‘What about all that data flowing around? Is it protected?’”

“There are those who don’t trust computers and may not feel confident that patient information is more secure with an EHR system,” says Reider. “But we remind those physicians that the cleaning lady has access to all those filed paper charts. There’s no way to monitor who is accessing files in the paper world, but if you’re using EHRs, it can easily be monitored who is accessing files and when they were accessed. And with an EHR, you don’t wind up with lost medical records either, a problem that practices do sometimes deal with, especially when transporting files between offices.”

In addition to tracking who is accessing files, an EHR can provide security in another way—by protecting data no matter what. “An EHR system can help provide ease during the disaster recovery process,” says Gunther. “Say, for instance, a building burns down. All paper records are lost. But if the practice has integrated EHRs, patient records are safe.”

On a slightly different note, EHRs can enhance patient safety and protect practices against malpractice suits through their safety features, says Reider. “These systems not only optimize value but also enhance the safety of the practice with features that can check for medication interactions and prevent errors,” he notes.

The Right System
Even for those physicians who have the necessary IT skills, usability is still a concern, notes Bell. “This boils down to those things that are important for the physician to have in order to take good care of his or her patients,” she explains. “Finding the right system means answering these questions: Does it organize data well? Does it provide you with ways to look at and present information? And, perhaps most importantly, does it make your life easier and less time consuming?”

Thornton says that when he went into the field to research some of the concerns with implementing EHRs, he repeatedly heard that doctors and nurses felt the systems decreased their productivity. “There can be such a steep learning curve that it actually affected the practices’ workflow,” he says. “Doctors said they ended up abandoning their systems or just using them for billing. But the real appeal in using EHRs is all of the possible charting aspects, so it’s important for physicians to find a system that they find both easily operable and that fits into the way they are already doing things.”

For instance, doctors have been taking notes for hundreds of years, continues Thornton. It’s something they feel comfortable doing. “A doctor’s note taking is a well-honed process that leads to good treatment, so implementing a system that requires a lot of searching and navigating takes them away from this process that they are familiar with,” he explains. “The solution is an EHR that supports a lot of open note taking. Many have handwriting recognition, but you have to enable that field or go through several steps to get it working. Doctors who want to simply use the system as an open notebook should be able to, as should those who want to use all of the special features. One size should be able to fit all because no two doctors or practices are alike. A successful EHR system is highly customizable and can support doctors who want the bare minimum all the way up to the doctors who are really tech savvy.”

Age Segmentation
Perhaps the only problem without a clear solution is the fact that many older physicians simply do not want to change the way their practice operates or put the money into a new system. “Physicians in their mid-50s may not want to be investing in technology; they want to invest in their retirement plan,” says Nissenbaum. “It can be a hard sell getting this physician to implement electronic media.”

“It is true that some of the older physicians simply might not feel as comfortable with the technology, so the real tipping point might be an intergenerational thing,” adds Gunther. “Obviously, there is a younger group of physicians who have grown up with this technology and want to use it. I’ve said before that if we ran our financial institutions the way we run our healthcare system, we would be living in the Stone Age. There will be that tipping point when the industry catches up to the technology.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.